For example, euphoric patients, in the middle of an exultant tirade proclaiming their grandeur, may suddenly be thrust into deep despair and wretched crying, only to return again within a very brief period of time to their former elated state. Or a patient may be sobbing uncontrollably, yet claim to feel exalted and then go on to perform a lively dance with tears still streaming down the face.

As affirmed by the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), a mixed state must meet the criteria for both a major depressive episode and a manic episode nearly every day for at least one week.[1] However, mixed episodes rarely conform to these qualifications; they may be described more practically as any combination of depressive and manic symptoms.[2][3][4]

The Merck Manual of Diagnosis and Therapy (MMDT) splits the DSM-IV diagnosis into two distinct states: dysphoric mania, which consists of a manic episode with depressive symptoms; and agitated depression, which is a "major depressive [episode] with superimposed hypomanic symptoms".[5]

According to the MMDT, increased energy and some form of anger, from irritability to full blown rage, are the most common symptoms of dysphoric mania. Symptoms may also include auditory hallucinations, confusion, insomnia, persecutory delusions, racing thoughts, restlessness, and suicidal ideation. Alcohol, drug abuse, and some antidepressant drugs may trigger dysphoric mania in susceptible individuals. A study by Goodwin and Ghaemi (2003) reported manic symptoms in two-thirds of patients with agitated depression, which they suggest calling "mixed-state agitated depression".[6]

^Muzina, D. J. (2009), Pharmacologic treatment of rapid cycling and mixed states in bipolar disorder: an argument for the use of lithium. Bipolar Disorders, 11: 84–91. doi:10.1111/j.1399-5618.2009.00713.x